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Member Materials and Forms | Ambetter from Home State Health
Member Resources
Many of our member resources, such as the member handbook and forms, can be found on our secure portal. Click Login to create an account and access a wide array of resources!
Member Handbook
Reference Materials
- Find a Provider Guide (PDF)
- Preventive Services Guide (PDF)
- Dr. Office Visit Checklist (PDF)
- Quality Improvement (QI) Program
- Referral and Authorization Information
- Statement of Non-Discrimination
- 2020 Transparency Notice
- 2019 Transparency Notice
- Where to go for Care
- Women's Health and Cancer Rights Act Annual Notice
Forms
- Authorization to Disclose Health Information Form (PDF)
- Revocation of Authorization Form (PDF)
- Grievance and Appeals Form (PDF)
- Member Reimbursement Medical Claim Form (PDF)
- Prescription Claim Reimbursement Form (PDF)
- Donor Transplant Travel Reimbursement Form (PDF)
- Recipient Transplant Travel Reimbursement Form (PDF)
- Member Transplant Travel Reimbursement Policy (PDF)